PEDIATRIC DAY HEALTH CARE PROVIDER MANUAL Chapter Forty-Five of the Medicaid Services Manual

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PEDIATRIC DAY HEALTH CARE

PROVIDER MANUAL

Chapter Forty-Five of the Medicaid Services Manual

Issued December 1, 2011

State of

Louisiana

Bureau of Health Services Financing

Claims/authorizations for dates of service on or after October 1, 2015

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SECTION: TABLE OF CONTENTS

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Page 1 of 2 Table of Contents

PEDIATRIC DAY HEALTH CARE

TABLE OF CONTENTS

SUBJECT

SECTION

OVERVIEW

SECTION 45.0

COVERED SERVICES

SECTION 45.1

Documentation Requirements Certification Period

Parental/Guardian Consent Durable Medical Equipment Medication

Transportation

Parent Guardian Authorization

PDHC Facility Transportation/Contracted Transportation PDHC Facility

Services Not Covered

RECIPIENT CRITERIA

SECTION 45.2

PROVIDER REQUIREMENTS

SECTION 45.3

Licensure

Maintaining Licensed Status Changes in Licensee Information Change in Ownership

Closure of a Facility

STAFFING REQUIREMENTS

SECTION 45.4

Administrator Medical Director Director of Nursing Registered Nurse

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SECTION: TABLE OF CONTENTS

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Page 2 of 2 Table of Contents

RECORD KEEPING

SECTION 45.5

Medical Records Personnel Records

REIMBURSEMENT

SECTION 45.6

Prior Authorization

Renewal of Prior Authorization Claim for Payment

PLAN OF CARE

SECTION 45.7

Requirement

Initial Plan of Care

Components Approval Renewal

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SECTION 45.0: OVERVIEW

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Page 1 of 1 Section 45.0

OVERVIEW

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SECTION 45.1: COVERED SERVICES

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COVERED SERVICES

The Medicaid Pediatric Day Health Care (PDHC) facility per diem includes the following services: • Nursing care; • Respiratory care; • Physical therapy; • Speech-language therapy; • Occupational therapy;

• Personal care services (activities of daily living); and

• Transportation to and from the PDHC facility. Transportation shall be paid in a separate per diem.

Documentation Requirements

The PDHC in order to provide services to a recipient must receive prior authorization. To receive prior authorization, the PDHC must submit the following documentation to the fiscal intermediary for each request:

• Physician’s Order for PDHC

Services shall be ordered by the recipient’s prescribing physician. A face-to-face evaluation must be held every four months between the recipient and prescribing physician.

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SECTION 45.1: COVERED SERVICES

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The order shall contain: • The recipient’s name; • Date of birth;

• Sex;

• Medicaid ID number;

• Description of current medical conditions including the specific diagnosis codes;

The parent/guardian’s name and phone number; and • The provider’s name and phone number.

The physician shall acknowledge if the recipient is medically stable for outpatient medical services. The physician shall sign, date and provide his NPI number. • “Request for Prior Authorization” PA-16 Form

Certification Period

The case shall be certified for a period not to exceed 180 days.

Parental/Guardian Consent

A signed parental/guardian consent is required for participation in the PDHC. The consent form shall outline the purpose of the facility, parental/guardian’s responsibilities, authorized treatment and emergency disposition plans.

A conference shall be scheduled prior to admission with the parent/guardian(s), PDHC representative, and the prescribing physician to begin development of the plan of care.

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SECTION 45.1: COVERED SERVICES

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Durable Medical Equipment

Medicaid cannot reimburse a PDHC for durable medical equipment (DME) and supplies that are provided to the recipient through the Medicaid DME program.

Medication

The parent or guardian is to supply medications each day as prescribed by the attending physician or by a specialty physician after consultation and coordination with the PDHC facility. PDHC staff shall administer these medications, as ordered or prescribed, while the recipient is on site.

Medications shall be kept in their original packaging and contain the original labeling from the pharmacy. The medication shall be individually stored in a secure location and Schedule II substances shall be kept in a separately locked and secure box in a secured designated area. The facility shall have established policies and procedures for the handling and administration of controlled substances. The facility shall maintain a record of medication administration. The record shall contain each medication ordered and administered; the date, time, and dosage of each medication administered; and the initials of the person administering the medication.

Transportation

The PDHC facility shall provide or arrange transportation of the recipient to and from the facility; however, no recipient, regardless of his/her region of origin, may be in transport for more than one hour on any single trip. The PDHC facility is responsible for the safety of the recipient during transport. The family may choose to provide their own transportation.

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SECTION 45.1: COVERED SERVICES

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Parent/Guardian Authorization

The parent/guardian shall provide a signed authorization designating the person(s) the recipient can be released to for transportation purposes. The authorization shall provide the location where the recipient can be picked up or dropped off. The release shall name the facility and to whom the recipient shall be released.

PDHC Facility Transportation/Contracted Transportation

Each driver or attendant shall be provided with a current master transportation list including • Each recipient’s name;

• Pick up and drop off locations; and

• Authorized `persons to whom the recipient may be released.

An attendance record shall be maintained by the driver or attendant for each trip. The record shall include the following:

• Driver’s name; • Date of the trip;

• Names of all passengers (recipient and adults) in the vehicle; and • Name to whom the recipient was released and the time of the release.

This record shall be signed by the driver or attendant and the PDHC representative who accepts and releases the recipient each day.

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SECTION 45.1: COVERED SERVICES

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Each recipient shall be safely and properly: • Assisted into the vehicle; • Restrained in the vehicle; • Transported in the vehicle; and • Assisted out of the vehicle.

The driver or appropriate staff person shall check the vehicle at the completion of each trip to ensure that no recipient is left in the vehicle.

During field trips, the driver or staff member shall check the vehicle and account for each recipient upon arrival at, and departure from, each destination to ensure that no recipient is left in the vehicle or at any destination.

Appropriate staff person(s) shall be present when each recipient is delivered to the facility.

PDHC Facility

The facility shall maintain an attendance record. The record shall include: • Method used to transport the recipient to and from the facility; • Name of the person transporting the recipient;

• Date and time of the release; and

• Signatures of the driver or parent/guardian and the PDHC representative.

Services Not Covered

The Medicaid PDHC per diem does not include the following services: • Education and training services;

• Before and after school care;

• Medical equipment, supplies and appliances; • Parenteral or enteral nutrition;

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SECTION 45.2: RECIPIENT CRITERIA

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Page 1 of 3 Section: 45.2

RECIPIENT CRITERIA

In order to qualify for pediatric day health care (PDHC) services, a recipient must meet all of the following criteria. The recipient must:

• Be Louisiana Medicaid eligible; • Be age birth up to 21 years of age;

• Require ongoing skilled medical care or skilled nursing care by a knowledgeable or experienced licensed professional registered nurse (RN) or licensed practical nurse (LPN);

• Have a medically complex condition(s) which requires frequent, specialized therapeutic interventions and close nursing supervision. Interventions are those medical procedures provided to sustain and maintain health and life. Interventions required and performed by individuals other than the recipient’s personal care giver would require the skilled care provided by professionals at PDHC centers. Examples of medically necessary interventions include, but are not limited to:

• Suctioning using sterile technique;

• Provision of care to a ventilator dependent and/or oxygen dependent recipient to maintain patient airway and adequate oxygen saturation, inclusive of physician consultation as needed;

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SECTION 45.2: RECIPIENT CRITERIA

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Page 2 of 3 Section: 45.2 • Maintenance and interventions for technology dependent recipients who

require such life-sustaining equipment; or

• Complex medication regimen involving, and not limited to, frequent change in dose, route, and frequency of multiple medications, to maintain or improve the recipient’s health status, prevent serious deterioration of health status and/or prevent medical complications that may jeopardize life, health or development;

• Have a medically fragile condition, defined as a medically complex condition characterized by multiple, significant medical problems that require extended care. Medically fragile individuals are medically complex and potentially dependent upon medical devices, experienced medical supervision, and/or medical interventions to sustain life.

Examples of medically fragile conditions include, but are not limited to: • Severe lung disease requiring oxygen;

• Severe lung disease requiring ventilator or tracheotomy care; • Complicated heart disease;

• Complicated neuromuscular disease; and • Unstable central nervous system disease. • Be stable for outpatient medical services; and

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SECTION 45.2: RECIPIENT CRITERIA

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Page 3 of 3 Section: 45.2 In the event, the medical director of the PDHC facility is also the recipient’s prescribing physician, the Department of Health and Hospitals reserves the right to review the prescription for the recommendation of the recipient’s participation in the PDHC Program.

NOTE: PDHC does not provide respite care and is not intended to be an auxiliary (back-up) for

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SECTION 45.3: PROVIDER REQUIREMENTS

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PROVIDER REQUIREMENTS

Licensure

The pediatric day health care (PDHC) facility must have a valid, current PDHC license issued by the Department of Health and Hospitals (DHH). DHH is the only licensing authority for PDHC facilities in the state of Louisiana. Each facility shall be separately licensed.

A parent or legally responsible person providing care to a medically fragile child in his/her home or any other extended care or long term care facility is not considered a PDHC facility and will not be licensed as a PDHC facility.

Maintaining Licensed Status

In order for a PDHC facility to maintain its licensed status and to be considered operational, the facility must meet the following conditions:

• The facility must have at least two employees, one of whom is a registered nurse and is on duty at the facility location during operational hours.

• The facility must have staff employed and available to be assigned to provide care and services to each recipient during operational hours. The services provided must be consistent with the medical needs of each recipient.

• The facility must have provided services to at least two recipients in the preceding 12 month period in order to be eligible to renew its license.

Changes in Licensee Information

A PDHC license is only valid for the person or entity named in the license application and only for the specific geographic address listed on the license application.

Any change in the PDHC facility name, “doing business as” name, mailing address, phone number, or any combination, must be reported in writing to DHH within five days of the occurrence. A change in the facility name or “doing business as” name requires a change to the facility license and requires a $25.00 fee for reissuance of an amended license.

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SECTION 45.3: PROVIDER REQUIREMENTS

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Change in Ownership

A change in ownership (CHOW) of the PDHC facility must be reported in writing to the DHH within five days of the change. The new owner must submit the legal CHOW document, all documents for a new license, and the applicable licensing fee. When all application requirements are completed and approved by the DHH, a new license will be issued to the new owner.

NOTE: A facility that is under license suspension, revocation or termination may not undergo a

CHOW.

Closure of a Facility

A PDHC facility that plans to close or cease operations must comply with the following procedures:

• Provide 30 days advance written notice to: • DHH;

• The prescribing physician; and

• The parent (s), legal guardian or legal representative.

• Notify DHH of the location where the records will be stored and the contact person for the records, and

• Provide for an orderly discharge and transition of all recipients admitted to the facility.

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SECTION 45.4: STAFFING REQUIREMENTS

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STAFFING REQUIREMENTS

Each pediatric day health care (PDHC) facility must adhere to all staffing and personnel guidelines outlined in the Minimum Licensing Standards for PDHC facilities.

Administrator

The administrator of the facility must be a full time employee and must designate in writing the individual who will be responsible for the facility when he/she is absent from the facility for more than 24 hours.

The administrator and the administrator’s designee must have three years of experience in the delivery of health care services, be at least 21 years of age, and meet one of the following criteria:

• A physician currently licensed in the state of Louisiana; • A registered nurse currently licensed in Louisiana; • A college graduate with a bachelor’s degree; or

• Have an associate degree with one additional year of documented management experience.

Responsibilities of the administrator/designee include, but are not limited to the following:

• Ensure that the facility complies with all federal, state, and local laws, rules and regulations.

• Maintain a daily census record of each recipient who receives services and records of all accidents, and incidents including alleged abuse and/or neglect involving any recipient or staff member.

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SECTION 45.4: STAFFING REQUIREMENTS

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• Maintain current agreements and contracts of individuals utilized by the facility. • Ensure that the facility develops and implements policies and procedures which

are included in the facility’s policy manual.

Medical Director

The medical director of the PDHC facility must be a physician currently licensed in Louisiana without restrictions.

The medical director must meet one of the following: • A board certified pediatrician

• A pediatric specialist with knowledge of medically fragile children; or

• A medical specialist or subspecialist with knowledge of medically fragile children.

The responsibilities of the medical director include, but are not limited to:

• Periodic review of services provided by the facility to assure acceptable levels of care and services;

• Participates in the reviews of the plan of care for each recipient receiving services;

• Consults with the prescribing physician and/or staff; and

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SECTION 45.4: STAFFING REQUIREMENTS

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Director of Nursing

Each facility must have a full time director of nursing (DON). The DON must be a registered nurse currently licensed in the state of Louisiana without restrictions and meet the following criteria:

• Hold a current certification in Cardio Pulmonary Resuscitation (CPR);

• Hold a current certification in Basic Cardiac Life Support and Pediatric Advanced Life Support; and

• Have a minimum of two years general pediatric nursing experience with at least six months caring for medically fragile or technology dependent infants or children.

The responsibilities of the DON include, but are not limited to the following:

• Supervision of all aspects of recipient care to ensure compliance with the plan of care;

• Daily clinical operations of the facility; • On-site during normal operating hours;

• Compliance with all federal and state laws, rules and regulations related to the delivery of nursing care and services; and

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SECTION 45.4: STAFFING REQUIREMENTS

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Registered Nurse

A PDHC facility must have sufficient RN staff to ensure that the care and services provided to each child is in accordance the child’s plan of care. The facility RN must have the following qualifications:

• Currently licensed in the state of Louisiana without restrictions; • Have a current certification in CPR; and

• Have one of the following:

• One or more years of experience as a RN with pediatric experience, which includes six months caring for medically fragile or technologically dependent children; or

• Two or more years of documented pediatric nursing experience as a licensed practical nurse with six months experience caring for medically fragile or technologically dependent children.

Licensed Practical Nurse

The facility must have sufficient licensed practical nurse (LPN) staff to ensure that the care and services provided to each child is provided in accordance with the plan of care. LPN’s employed by the facility must meet the following qualifications and experience:

• Be licensed in the state of Louisiana without restrictions • Hold a current certification in CPR; and

• Have one of the following:

• One or more years of experience in pediatrics as an LPN; or

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SECTION 45.4: STAFFING REQUIREMENTS

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Direct Care Staff

Direct care staff will work under the supervision of the RN and will be responsible for providing direct care to children at the facility.

Direct care staff should meet the following qualifications and experience:

• One year documented employment experience in the care of infants or children or one year experience in caring for medically fragile children

• Hold a current certification in CPR, • Be 18 years or older;

• Currently registered with the Certified Nurse Aide (CNA) Registry as a CNA in good standing and without restrictions; and

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SECTION 45.5: RECORD KEEPING

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RECORD KEEPING

Medical Records

Each recipient shall have a medical record developed at the time of acceptance at the pediatric day health care (PDHC) facility and maintained throughout the facility’s care of the recipient. The recipient’s medical record must be signed by authorized personnel and contain at least the following documents:

• Medical plan of treatment and nursing plan of care; • Referral and admission documents;

• Physician orders; • Medical history;

• Immunization documentation;

• Medication/treatment administration record; • Case notes;

• Documentation of nutritional management and diet;

• Documentation of physical, occupational, speech and other therapies; • Correspondence concerning the recipient;

• An order written by the prescribing physician if the recipient terminates services with the facility, if applicable; and

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SECTION 45.5: RECORD KEEPING

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Personnel Records

Personnel records must be kept in a place, form and system in accordance with appropriate medical and business practices. All records must be available in the facility for inspection by the Department of Health and Hospitals during normal business hours.

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SECTION 45.6: REIMBURSEMENT

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REIMBURSEMENT

Reimbursement for pediatric day health care (PDHC) services shall be a statewide fixed per diem rate which is based on the number of hours that a qualified recipient attends the PDHC facility. Transportation to the facility will be reimbursed separately.

• A full day of service is more than four hours, not to exceed a maximum of 12 hours per day.

• A partial day of service is equal to four hours or less per day.

Reimbursement shall only be made for services that have been prior authorized by the Medicaid Program or its approved designee.

Prior Authorization

PDHC services must be prior approved by the fiscal intermediary’s Prior Authorization Unit (PAU). Prior authorization (PA) requests should include the following:

• PA Request form;

• PDHC Physician Order and Plan of Care form; • PDHC PA Checklist; and

• Any additional supporting medical documentation. Upon receipt of the request, the PAU will:

• Assign each request a unique PA number,

• Review each request for completion of all required documentation, and • Determine the recipient’s necessity for PDHC services.

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SECTION 45.6: REIMBURSEMENT

PAGE(S) 2

The recipient, case manager and PDHC facility will receive a written notification informing them of approval or denial of the request. If services are approved, the notice will include the approval period.

NOTE: An approved prior authorization is not a guarantee that Medicaid will reimburse the

service. The provider and recipient must both be eligible on the date of service, and the service must not exceed the weekly approved hours.

Questions concerning the PA process should be directed to the PAU (see Appendix D for contact information).

Renewal of Prior Authorization

Re-evaluation of PDHC services must be performed, at a minimum, every 120 days. Services shall be revised during evaluation periods to reflect accurate and appropriate provision of services for current medical status. This evaluation must include:

• A review of the recipient’s current medical Plan of Care (POC),

• A provider agency documented current assessment and progress toward goals, • Documentation of a face-to-face evaluation between the prescribing physician and

recipient shall be held every four months, and

• A completed “Request for Prior Authorization” PA-16 Form.

The fiscal intermediary will review the forms to determine the documentation is complete and that services continue to be medically necessary and appropriate to reauthorize the services. A notification of the decision will be sent to the recipient, case manager, and PDHC facility.

Claim for Payment

PDHC providers should submit a claim for payment for prior authorized services once the service has been provided.

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SECTION 45.7: PLAN OF CARE

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PLAN OF CARE

An individualized plan of care (POC) addressing the recipient’s problems, goals, and required services shall be developed under the direction of the facility’s nursing director in collaboration with the prescribing physician prior to placement in the facility. The POC shall ensure the recipient’s developmental needs are addressed; identify specific goals for care, and plans for transition to discontinuation of care. The POC must be signed by the parent/guardian, pediatric day health care (PDHC) representative, and prescribing physician. A copy shall be given to the prescribing physician and to the parent/guardian if requested. The facility shall retain a copy in their records. Services shall be administered in accordance with the POC. The POC is written to cover a specific time frame. The plan for achieving the goals shall be determined and a schedule for evaluation of progress shall be established.

Requirement

Once a referral has been received by the PDHC center the recipient will attend, a POC shall be developed under the direction of the facility’s nursing director. The development of the plan shall begin within 72 hours of the referral. A POC is required prior to the first day PDHC services begin.

The POC should be developed under the direction of the facility’s nursing director and in collaboration with the prescribing physician. The recipient’s treatment plan must consider and reflect all services the recipient is receiving, including waiver and other community supports and services. The POC for continuation of services shall be reviewed and updated at a minimum, every 180 days or as indicated by the needs of the recipient.

Initial Plan of Care

Components

• Provider Information - Name and Medicaid provider number • Start of care date and certification period

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SECTION 45.7: PLAN OF CARE

PAGE(S) 3

• Other special orders/instructions

• Medications, treatments, and any required equipment • Monitoring criteria, monitoring equipment and supplies • Nursing services to be provided

• Diet as indicated and how recipient is to be fed

• Recipient’s current medical condition and hospitalizations within last six months • Risk factors associated with medical diagnoses

• Special goals for care identified: Plans for achieving the goals shall be determined and an evaluation schedule of progress shall be established

• Frequency/Duration of PDHC services – number of days/week; hours/day or duration

• All services the recipient is receiving, including waiver and other community supports and services must be considered and reflected.

• Discharge plans – contain specific criteria for transitioning from or discontinuing participation in the PDHC with the facility

• For Recertification only – accomplishments toward goals; assessment of effectiveness of services; acknowledgment of face-to-face evaluation between recipient and prescribing physician every four months

Approval

The POC must be signed by the prescribing physician, an authorized representative of the facility and the recipient’s parent/guardian. All signatures on the POC must be legible and dated.

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SECTION 45.7: PLAN OF CARE

PAGE(S) 3

The facility staff shall administer services and treatments in accordance with the POC as ordered by the physician.

Renewal

The POC for continuation of services shall include the above components. In addition, the revised POC shall include accomplishments toward goals; assessment of the effectiveness of services; and acknowledgment of face-to-face evaluation between recipient and prescribing physician every four months. The renewal must:

• Be reviewed and updated, at a minimum, every 120 days or as indicated by the needs of the recipient

• Consider and reflect all services the recipient is receiving, including waiver and other community supports and services

• Be completed by registered nurse of the facility • Be reviewed and ordered by the prescribing physician

• Be incorporated into the recipient’s clinical record within seven calendar days of receipt of the prescribing physician’s order

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SECTION 45.8: QUALITY ASSURANCE

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QUALITY ASSURANCE

All PHDC facilities must have a quality assurance program and conduct quarterly reviews of the facility’s medical records for a fourth of the recipients served by facility at the time of the assurance review. The review sample should be random so that each recipient at the facility has an equal chance to be included in the review.

Each facility must establish a quality assurance committee comprised of the following members: • The medical director;

• The administrator;

• The director of nursing; and

• Three other committee members determined by the facility. The quarterly assurance review will include;

• A review of the goals of the recipient’s plan of care, • The steps and success in achieving the goals;

• Identification of goals not achieved; • Plans to promote goal achievement; • Recommendations to be implemented; and

• A review of previous recommendations to determine the effectiveness of the implementation.

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SECTION: APPENDIX A - DEFINITIONS

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Page 1 of 2 Appendix A

DEFINITIONS

Medically Complex

An individual considered medically complex has one or more chronic, debilitating diseases or conditions involving one or more physiological or organ systems. Medically complex individuals require skilled medical care, professional observation or medical intervention.

Medically Fragile

An individual who has a medically complex condition characterized by multiple, significant medical problems that require extended care. Medically fragile individuals are medically complex and potentially dependent upon medical devices, experienced medical supervision, and/or medical interventions to sustain life.

Medically Necessary

Medicaid reimburses for services that are determined medically necessary, do not duplicate another provider’s service, and meets the following conditions:

• Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;

• Be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs; • Be consistent with generally accepted professional medical standards as

determined by the Medicaid program and not experimental or investigational; • Be reflective of the level of service that can be safely furnished, and for which no

equally effective and more conservative or less costly treatment is available statewide; and

• Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.

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SECTION: APPENDIX A - DEFINITIONS

PAGE(S) 2

Page 2 of 2 Appendix A

Parent

The individual who has legal custody of the child is considered the parent.

Plan of Care

The comprehensive plan developed by the pediatric day health care (PDHC) facility for each child to receive services for implementation of medical, nursing, psychosocial, developmental, and educational therapies.

Prescribing Physician

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SECTION: APPENDIX B – PROCEDURE CODES

PAGE(S) 1

PROCEDURE CODES

This section lists the procedure codes and maximum fees that Medicaid reimburses for Pediatric Day Health Care (PDHC) services.

Procedure Codes

The procedure codes listed in this manual chapter are Healthcare Common Procedure Coding System (HCPCS) codes, Level II. The codes are part of the standard code set described in HCPCS Level II book. Please refer to the HCPCS Level II book for complete descriptions of the standard codes. Level II codes are national codes usually used to describe medical services and supplies. They are distinguished from Level 1 codes by beginning with a single letter (A through V) followed by four numeric digits.

In compliance with the federal requirements found in the Health Insurance Portability and Accountability Act (HIPAA), the Medicaid Program will process claims for only the standard code sets allowed in the federal legislation.

Diagnosis Codes

Diagnosis codes are found in the International Classification of Diseases, Clinical Modifications (ICD-10-CM or its successor). A diagnosis code is required on the CMS-1500 claim. The most specific code, including fourth and fifth digits, when available, must be used.

Units of Service

Medicaid reimburses PDHC services at a fixed rate based on the number of hours per day that the recipient attends the PDHC facility. There are two reimbursement rates, one for a full day, up to 12 hours, and one for a partial day of services, for four hours or less.

Procedure Code T1025 shall be used for a full day of service and Procedure Code T1026 shall be used for a partial day of service.

If a recipient is approved for full days of PDHC services, Procedure Code T1026 shall be automatically generated, with the prior authorization, for a percentage of the number of days approved for T1025. This is to be used on days when the child cannot attend for the full day so that providers can bill for the actual service hours of 4 hours or less. These two procedure codes cannot be billed for the same day.

Procedure Code T 2002 shall be used for transportation.

For reimbursement purposes, PDHC services begin when the PDHC staff assumes responsibility for the care of the child and ends when care is relinquished to the parent or guardian.

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SECTION: APPENDIX C – FEE SCHEDULE

PAGE(S) 1

Page 1 of 1 APPENDIX C

PDHC SERVICES

FEE SCHEDULE

CODE DESCRIPTION OF SERVICE MAXIMUM FEE

T 1025 Full-Day PDHC Services (over four hours up to

twelve hours per day) ** $293.72/day T 1026 Hourly PDHC Services – (four hours or less per day-) $42.01/hour

T 2002 Transportation Per Diem $29.40/day

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APPENDIX D: CONTACT/REFERRAL INFORMATION PAGE(S) 1

Page 1 of 1 Appendix D

CONTACT/REFERRAL INFORMATION

OFFICE NAME TYPE OF ASSISTANCE CONTACT INFORMATION

Health Standards Section (HHS)

Office to contact to report changes that affect provider

license

Health Standards Section P.O. Box 3767 Baton Rouge, LA 70821 1-800-660-0488 Fax: (225) 342-5292 Division of Administrative Law –

Health and Hospitals Section

Office to contact to request an appeal hearing

Division of Administrative Law - Health and Hospitals Section

P. O. Box 4189

Baton Rouge, LA 70821-4189 (225) 342-0443

Fax: (225) 219-9823

Phone for oral appeals: (225) 342-5800

Prior Authorization Unit (PAU)

Office to contact to obtain assistance with prior authorization issues, reports,

and forms

Molina Medicaid Solutions Prior Authorization Unit

P.O. Box 14919 Baton Rouge, LA 70898-4919 1-800-488-6334 Fax: (225) 929-6803 Provider Enrollment Unit (PEU)

Office to contact to report changes in agency ownership,

address, telephone number or account information affection

electronic funds transfer

Molina Medicaid Solutions Provider Enrollment Section

P. O. Box 80159

Baton Rouge, LA 70898-0159 (225) 216-6370

Provider Relations (PR) Unit

Office to contact to obtain assistance with questions regarding billing information

Molina Medicaid Solutions Provider Relations Unit

P. O. Box 91024 Baton Rouge, LA 70821

1-800-473-2783

Office of Community Services - Local Child

Protection Hotline

Office to contact to report suspected cases of abuse, neglect, exploitation or extortion of a recipient under

the age of 18

Refer to the Department of Children and Family Services website at:

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